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P"-- <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUr%1-Kt:I-UN1JAt3Lt rtK T <br />GALL [Uy t�JOJ-/ba/ FOR INSPECTIONS tAl'IKh5 FROM LIA2TE ISSUED <br />Jos ADDRESS <br />� `� <br />/9 /YEAR <br />Cm/L+P/� i/L +C/W- 9533 3 <br />�` A y� J <br />CROSS STREET. F. / 1 G - f r Q_. Ula �� <br />1 �V( <br />I 1 t) <br />�/ <br />O D PARCEL SIZE I' "ZLAND USE APPLICATION # <br />I-APN <br />OWNER NAME u ";n CIIA �Q©f el <br />OWNERADDRESS q w�I�yr <br />V1 PHONE 1__ 1_ �/'� <br />CITY/STATE21P. S 1 OG kb� GAI9S 63 <br />CONTRACTOR Kleinfelder <br />PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch -Airport Rd. Suite 100 CITY/STATE/LP Stockton r Ca. 95206 <br />SUBCONTRACTOR V&W Drilling <br />PHONE 209-469-7700 <br />SUBCONTRACTOR ADDRESS 3806 Duck <br />Creek Dr. <br />cm/STATE/mp Stockton, Ca. 95215 <br />LICENSE $ C-57 D C-61 D D-09 <br />D Other <br />NUMBER 720904 EXPIRAT ON DATE d z -4 O 2 O 18 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. water System Name ContaCt Name or Phone Number <br />TYPE OF WORK ❑ New Well D Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells D Soil Boring(s) # of bodngs )(Geotechnical # of borings <br />D Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />LI Kafse Well <br />Drilling Method 1, Mud Rotary D Air Rotary )( Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth�,Oft Excavation C— In diameter D Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />G Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad D Steel CI Plastic D Stainless Steel f_I Other <br />Grout Seal Depth5, 0ft (, Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix(7 gal water <br />(:) Bentonite (20% solids) 0 Other <br />Grout Placement Method (Pumped 0 Free Fall IJ Other o Retardant /Accelerator (name) <br />PEDESTAL Installed By D Driller 1:1 Pump Contractor 1:1 Other <br />Concrete Pedestal Ll Dimensions: Width ft Length ft Thick in D Christy Box D Stove Pipe <br />PUMP D Submersible IJ Turbine D Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Date <br />0 <br />X <br />N <br />rn M <br />t� <br />m3 <br />M <br /><Z <br />o m <br />Employee ID#b**V <br />Received Check#/ Amount Date <br />B Cash Remitted <br />❑ 1 SPECIAL Well Permit <br />❑ WAIVER Received <br />P �a <br />Constructed Well Depth ft <br />PE I SC <br />Codes Info <br />Received Check#/ Amount Date <br />B Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />M C- <br />P �a <br />EHD 43-08 WELL /PUMP PERMIT <br />4/30112 <br />